NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Who Presents this Notice
OFFOR Med, Inc. d/b/a SmileMD (“SMILEMD”), its employees, and workforce members who are involved in providing and coordinating health care are all bound to follow the terms of this Notice of Privacy Practices (“Notice”). SMILEMD will share PHI for the treatment, payment and health care operations as permitted by HIPAA and this Notice.
SMILEMD is required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this notice of legal duties and privacy practices with respect to your Protected Health Information. SMILEMD uses computerized systems that may subject your Protected Health Information to electronic disclosure for purposes of treatment, payment and/or health care operations as described below. When SMILEMD uses or discloses your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
SMILEMD is required by law to protect the privacy of your medical information, distribute this Notice of Privacy Practices to you, and follow the terms of this Notice. SMILEMD is also required to notify you if there is a breach or impermissible access, use or disclosure of your medical information.
Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, your written authorization must be obtained in order to use and/or disclose your PHI. However, SMILEMD does not need any type of authorization from you for the following uses and disclosures:
Uses and Disclosures for Treatment, Payment and Health Care Operations. Your PHI may be used and disclosed to treat you, obtain payment for services provided to you and conduct “health care operations” as detailed below:
Treatment. Your PHI may be used and disclosed to provide treatment and other services to you–for example, to diagnose and treat your injury or illness. In addition, you may be contacted to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your PHI may also be disclosed to other providers involved in your treatment.
Payment. Your PHI may be used and disclosed to obtain payment for services provided to you–for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) or to verify that Your Payor will pay for health care.
Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you. For example, PHI may be used to evaluate the quality and competence of physicians, nurses and other health care workers. PHI may be disclosed to resolve any complaints you may have and ensure that you have a comfortable visit. Your PHI may be provided to various governmental or accreditation entities. In addition, PHI may be shared with business associates who perform treatment, payment and health care operations services on behalf of SMILEMD.
Additionally, your PHI may be used or disclosed for the purpose of allowing providers and others who are interested in healthcare, pursuing careers in the medical field or desire an opportunity for an educational experience to tour, shadow employees and/or clinical members or engage in a clinical program.
Disclosure to Relatives, Close Friends and Other Caregivers. Your PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you who is involved in your health care or helps pay for your care. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, SMILEMD may exercise professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to a family member, other relative or a close personal friend, SMILEMD would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.
Public Health Activities. Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
Health Oversight Activities. Your PHI may be disclosed to a health oversight agency that is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement Officials. Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena. For example, your PHI may be disclosed to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or criminal conduct at the facility.
Correctional Institution. You PHI may be disclosed to a correctional institution if you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain requests to us.
Organ and Tissue Procurement. Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
Research. Your PHI may be used or disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.
Health or Safety. Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
U.S. Military. Your PHI may be use or disclosed to U. S. Military Commanders for assuring proper execution of the military mission. Military command authorities receiving protected health information are not covered entities subject to the HIPAA Privacy Rule, but they are subject to the Privacy Act of 1974 and DoD 5400.11-R , “DoD Privacy Program,” May 14, 2007.
Other Specialized Government Functions. Your PHI may be disclosed to units of the government with special functions, such as the U.S. Department of State under certain circumstances for example the Secret Service or NSA to protect the country or the President.
Workers’ Compensation. Your PHI may be disclosed as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
As Required by Law. Your PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories; such as required by the FDA, to monitor the safety of a medical device.
Appointment Reminders. Your PHI may be used to tell or remind you about appointments.
Fundraising. Your PHI may be used to contact you as a part of fundraising efforts, unless you elect not to receive this type of information.
USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION
Use or Disclosure with Your Authorization. For any purpose other than the ones described above, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before your PHI can be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
Marketing. Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials. However, SMILEMD may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization. In addition, SMILEMD may send you treatment communications, unless you elect not to receive this type of communication, for which SMILEMD may receive financial remuneration.
Sale of PHI. SMILEMD will not disclose your PHI without your authorization in exchange for direct or indirect payment except in limited circumstances permitted by law. These circumstances include public health activities; research; treatment of the individual; sale, transfer, merger or consolidation of SMILEMD; services provided by a business associate, pursuant to a business associate agreement; providing an individual with a copy of their PHI; and other purposes deemed necessary and appropriate by the U.S. Department of Health and Human Services (HHS).
Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental illness, mental retardation and developmental disabilities; (3) is about alcohol or drug abuse or addiction; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about communicable disease(s), including venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult; or (9) is about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, SMILEMD is not required to agree to these requested restrictions.
You may also request to restrict disclosures of your PHI to your health plan for payment and healthcare operations purposes (and not for treatment) if the disclosure pertains to a healthcare item or service for which you paid out-of-pocket in full.
If you wish to request additional restrictions, please contact the Chief Compliance Officer. A written response will be sent to you.
Right to Receive Confidential Communications. You may request, and SMILEMD will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
Right to Revoke Your Authorization. You may revoke any written authorization obtained in connection with your PHI, except to the extent that SMILEMD has taken action in reliance upon it, by delivering a written revocation statement to the Chief Compliance Officer as identified below.
Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by SMILEMD in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please contact the Privacy Officer at the address identified below. If you request copies of paper records, you may be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper form (e.g., x-ray films), you will be charged the reasonable cost of the copies. You also will be charged for the postage costs, if you request that the copies be mailed to you. However, you will not be charged for copies that are requested in order to make or complete an application for a federal or state disability benefits program.
Right to Amend Your Records. You have a right to request that we amend or correct your health information that you believe is incorrect or incomplete. For example, if your date of birth is incorrect, you may request that the information be corrected. To request a correction or amendment to your health information, you must make your request in writing and provide a reason for your request. You have the right to request an amendment for as long as the information is kept by or for us. Under certain circumstances we may deny your request. If your request is denied, we will provide you with information about our denial and how you can file a written statement of disagreement with us that will become part of your medical record.
Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years.
Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
For Further Information or Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the Privacy Officer. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Chief Compliance Officer will provide you with the correct address for the Director. SMILEMD will not retaliate against you if you file a complaint with the Privacy & Security Compliance Office or the Director.
Effective Date and Duration of This Notice
Effective Date. This Notice is effective on July 1, 2022.
Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that the SMILEMD maintains, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted on our Internet site. You also may obtain any new notice by contacting the Chief Compliance Officer at contact information provided below.
Attn: Chief Compliance Officer
1103 Schrock Road, Suite 201
Columbus, OH 43229